Managing Your Horse’s Joints with Injections

Credit: Amy K. Dragoo Based on both current veterinary research and their experiences in practice, Dr. Weston Davis, Dr. Scott Swerdlin and Dr. Cricket Russillo agree that when it comes to joint injections for dressage horses moving up the levels, it’s really more a question of “when” than “if.”

As humans who spend our days riding and caring for 1,000-plus-pound animals, we may brush aside our own minor joint pains, treating symptoms by popping the occasional over-the-counter pain pill, soaking in a hot tub, drinking a glass of red wine or using a variety of sworn-by home remedies. While we may not be completely pain free, these kinds of minor aches and pains in humans can really seem to be more of a self-care issue than a cause for medical intervention. It’s easy to believe that if the above holds true for us, it must also be true for our horses. However, the wear and tear on a horse’s joints, and perhaps most relevantly on the joints of a dressage horse training through the upper levels, is quite different from that placed on the joints of the average human or even of the horse engaged in less strenuous activity.

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Dr. Scott Swerdlin, president of Palm Beach Equine Clinic, has been practicing veterinary medicine for more than 30 years and specializes in lameness in performance horses. According to Swerdlin, joint-care management is of particular importance for dressage horses. He explains, “In reality, I don’t know a horse who is competing at Prix St. Georges or higher who has not had routine medical joint support. The reason for that is what we’re trying to do in the sport. Rarely is a horse under 9 years of age performing any of the ‘Ps’ [piaffe , passage, pirouette] and, even at 9, it’s almost unheard of. Once they are intellectually able to perform these movements, they are already into their teens. It’s the athletic equivalent of me playing quarterback for the Jets at 60 years of age.”

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Therefore, joint-care management in the dressage horse should be proactive throughout the horse’s career. Intra-articular therapy, commonly referred to as joint injections, is an important component. Dr. Cricket Russillo, who practices with Virginia Equine Imaging and specializes in equine lameness with a focus on the elite performance horse, explains: “Joint injections are a procedure whereby a veterinarian places a needle inside a synovial structure and administers medication.” Russillo, who has herself competed through Third Level, also explains that there are two reasons for joint-injection procedures. The first is to administer a local anesthetic into the joint capsule. This is a diagnostic procedure commonly known as blocking, where the goal of the procedure is to isolate the source of a lameness. The second is to administer intra-articular therapy, a procedure that requires the veterinarian administer a corticosteroid or alternative medication with similar effect into the joint with the purpose of reducing or preventing inflammation. Russillo explains that the frequency, type and location of injections vary from horse to horse and depend largely on his level of use. “For a dressage horse in average work, we may treat the coffin joints and the lower hock joints,” explains Russillo. “When horses get to the upper levels, they often begin to need support in the stifle or sacroiliac joints as well.”

The Right Time for Joint Injections

According to Swerdlin, he rarely treats a dressage horse with joint injections because of an actual lameness. Rather, joint injections are part of proactive management, which helps a horse to be most comfortable at work and thus maximize his performance. Swerdlin explains, “We’re typically called by dressage riders or owners because of things like lack of impulsion, problems with collection or the canter pirouette not being as clean as it used to be. In other words, in dressage horses, injections are often predicated not by lameness issues, but by performance issues. It’s part of what’s so fun about working with dressage horses—we’re rarely looking at lame horses.”

Dr. Weston Davis, who practices alongside Swerdlin at Palm Beach Equine Clinic, is a veterinary surgeon specializing in sports medicine and surgery. Davis emphasizes that the time to think about joint-care management is early on in a horse’s performance career, before a significant problem occurs. “One of the things we consider important prognosis-wise for the horse is early intervention,” says Davis. “Early intervention is important for a successful outcome for the horse, as conditions drifting to chronic stages tend to have a more guarded prognosis for resolution and future athletic soundness.”

Swerdlin and Davis believe in a team approach to diagnostics and, depending on the horse, a radiologist, surgeon, the horse’s regular veterinarian and rider/trainer may all weigh in on the best approach for an individual horse’s joint-care management. Swerdlin emphasizes the importance of the owner/rider tracking the horse’s performance. This can help the veterinary team decide when intra-articular therapy is warranted. “Dressage owners are usually quite well-informed,” he says. “That’s helpful because we can really ask the rider—what do you think? What would you like to do? We get some really helpful feedback by listening to what the knowledgeable rider is feeling from her horse.” A horse may show subtle differences in performance, such as one-sidedness or decreased willingness, throughness or expression, any of which could indicate the horse would benefit from proactive joint support in the form of injections.

Russillo agrees that owner participation can be a significant factor in deciding when and how to proceed with injections. She advises, “When difficulties develop in a horse’s training, it’s important to ask: Is this a training issue or a veterinary issue? We’ll do a comprehensive exam and more often than not there may be a veterinary issue or we’ll find it’s a combination of both. If your horse has sore feet—and by feet I mean coffin joint or navicular region inflammation—that’s going to be part of why you’re having difficulties with his performance.” Russillo explains that a horse may not be showing signs of visual lameness, but that a joint injection may still be deemed necessary after a comprehensive examination that includes palpation of the legs and spine, flexion tests and a performance evaluation.

Take-Home Message

Based on both current veterinary research and their experiences in practice, Davis, Swerdlin and Russillo agree that when it comes to joint injections for dressage horses moving up the levels, it’s really more a question of “when” than “if.” The pros of the procedure far outweigh the cons. According to Russillo, the main advantage she sees in administering intra-articular therapy is to support the comfort of the horse in performance training. “I want the horse to be as comfortable as possible so we can harness his best performance. I believe that injections done correctly help the horse be the best version of himself.”

Davis also views the procedure as a component of preventive care for many sport horses. “If we have an inflammatory process going on in that joint, even a very low-grade synovitis, stopping the inflammatory cycle can be beneficial to avoid a catabolic, or degenerate, cycle of events. Inflammation left unchecked can send them down the degenerative path to arthritis. By appropriately medicating the joint and eliminating concurrent predisposing factors, we’re aiming to break the cycle.’”

Davis advocates an individualized approach to when treatments begin and how often they take place. Even at the upper levels, he sees some horses who have only a low-grade synovitis and can perform more comfortably with injections every four to six months or even annually before the competitive season. In some cases, horses may be treated once to break the inflammatory cycle and special attention to correction of external contributing factors may prevent the need for continued intra-articular therapy. “If we identify predisposing factors that we can fix, we eliminate them” says Davis. “This might include the horse’s shoeing, work surface or work protocol.” This is a crucial part of the long-term management.

Russillo adds that intra-articular therapy, properly done, can extend the horse’s performance lifespan. She cites a recent example: “I recently took hock radiographs on a 16-year-old, upper-level dressage horse who has been in my care for past five to six years, having his hocks done one to two times a year as needed for that entire time. We had repeated the radiographs just to check in—there hadn’t been any soundness issues. When comparing his 9-year-old hocks to his 16-year-old hocks, the radiographs showed no joint remodeling whatsoever. He’s a great example of a case where, with proactive management, we were likely able to stave off joint abuse, meaning arthritis, by preventing chronic inflammation. This, in turn, extended the horse’s performance lifespan.”

Oral Joint Supplements

There is an abundance of orally administered joint-health supplements on the market, and many owners and trainers swear by their effectiveness. However, buyer beware! Dr. Davis advocates: “Horse owners really need to be careful when selecting supplements. Get one that has a little bit of science behind it. There’s so many out there, and most of them have not been adequately validated to support their use.”

Credit: Arnd Bronkhorst - anrd.nl

Owners should always consult with their veterinarians and do some research before feeding oral joint supplements, remaining aware that veterinary consult is especially important with certain more vulnerable equine populations (pregnant mares, very young horses, horses with circulatory issues or sugar sensitivity). The following ingredients are widely available under various brand names and are often administered in conjunction with one another:

Chondroitin sulfate is a sugar molecule naturally occurring in the horse’s cartilage, bones, tendons and ligaments. In supplement form, it has been given to horses with joint issues for many years, often in powder or pellet form in conjunction with glucosamine. Despite its wide use over the past 30 years, medical research to support its effectiveness is minimal.

Glucosamine is a sugar compound made in the body and an inherent component of joint cartilage. According to the American Association of Equine Practitioners, “A number of test-tube studies have shown that glucosamine has biological activity and various beneficial effects on cartilage cells. While this should be great news, it should be noted that these studies have generally been conducted with levels of glucosamine that can’t be reached when the substance is fed to horses.”

MSM stands for methylsulfonylmethane, commonly known as sulfur. Sulfur is needed in the production of collagen, and thus advocates of MSM claim this supplement supports collagen production and acts as an anti-inflammatory. MSM can be taken alone or in combination with other joint-health supplements, such as glucosamine and chondroitin.

Hyaluronic acid (HA) is administered as an intra-articular injection, but it is also available in liquid and pelleted form as an oral supplement. HA occurs naturally in healthy joints, supporting the lubricating qualities of synovial fluid and cartilage resilience. As an oral supplement, it is often administered in combination with other joint supplements.

Resveratrol (RVA) is the powerful anti-oxidant also found in red grapes. It can be fed to horses in powdered, pelleted or paste forms, often in combination with HA. A recent Texas A&M clinical study showed positive indications that receiving resveratrol as an oral supplement enhanced and extended the effectiveness of intra-articular therapy in performance horses. (And, as for that glass of red wine riders sometimes turn to for relief of those minor aches and pains? It’s also high in resveratrol and may actually be doing our joints some good!)

Misconceptions

While Russillo and Swerdlin agree that there are few cons to intra-articular therapy, there are a few considerations as well as some common misconceptions about the procedure. “One in every 10,000 horses may get a little infection following the procedure,” explains Swerdlin. “The small risk shouldn’t deter people from trying to do what’s best for their horse.”

Russillo says owners sometimes question the practice of administering joint injections preventively to a currently sound horse. Owners may ask, “Doesn’t injecting harm or hurt the horse’s healthy joints?” According to Russillo, this is a misconception that she feels may stem from a faulty association of the low-dose corticosteroid used in intra-articular therapy with the potentially harmful use of banned anabolic steroidal medications for performance enhancement. She explains, “Intra-articular therapy is quite different, involving a different type of steroid and dosage, and being done for a different purpose. I think this perceived disadvantage may be a carryover from problems that occurred with the medications that were available back when joint injections first became a common procedure. Today, we are using medications that have been proven not to cause damage to cartilage, so the procedure has virtually no cons for the horse.”

Swerdlin has encountered a similar misconception in his practice—namely, that joint injections are “unnatural” and it would be preferable to treat the horse’s joint care needs homeopathically. Swerdlin advocates: “Think of it this way—there’s nothing more natural than fighting inflammation, breaking the cycle of inflammation and doing what’s best for the horse. At the upper levels of dressage, horses just need more support than homeopathy can offer.”

The Cost of Joint Injections

Dr. Russillo acknowledges that the cost of joint injections can be a factor, citing the example of a young rider who may be competing with a horse who has already worked his way through the levels with a professional. This horse may require more extensive maintenance to continue to perform and cost becomes a consideration. Russillo emphasizes, “While these procedures can stretch the budget in some cases, there are a lot of options out there, including payment plans, that can help owners do what is best for the horse.”

Good Horsemanship as Prevention

Credit: Beth Baumert When it comes to soundness management for performance horses, there’s simply no replacement for good horsemanship. Shown here is Rachel Chowanec and Heinsgardens Cado, owned by Denise Sarnoff.

When it comes to joint-care management in dressage horses, Russillo says there’s no substitute for good horsemanship. “This means daily palpations and knowing your horse’s legs,” she says. “Sometimes for a top performer, a really good groom will be doing this, but in many cases, it’s the owner or rider herself. Run your hands down the legs daily—check for swelling, heat or any other changes. These are the predictors of inflammation. In a best-case scenario, we want to catch this before it becomes a problem. In many cases, there is a sign there before the horse goes lame. For both joint and ligament injuries, there’s a major prognostic advantage if you can catch these signs early on. Often a ligament injury might be a tipoff for joint issues. In any case, when it comes to soundness management for performance horses, there’s simply no replacement for good horsemanship.”